HIV and Pregnancy Prevention of Motherto Child Transmission

HIV and Pregnancy: Prevention of Mother-to. Child Transmission (ВИЧ и беременность: профилактика передачи от матери к ребенку) Advances in Maternal and Neonatal Health HIV and Pregnancy

Pregnancy Effects on HIV l In all women, the absolute CD 4 count decreases no matter whether HIV-positive or negative (pregnancy does not make HIV worse) l In HIV-positive women, percentage of CD 4 cells should not change and viral load should not change because of pregnancy HIV and Pregnancy 2

Adverse Pregnancy Outcomes and Relationship to HIV Infection Pregnancy Outcome Relationship to HIV Infection Spontaneous abortion Limited data, but evidence of possible increased risk Stillbirth No association noted in developed countries; evidence of increased risk in developing countries Perinatal mortality No association noted in developed countries, but data limited; evidence of increased risk in developing countries Newborn mortality Limited data in developed countries; evidence of increased risk in developing countries Intra-uterine growth retardation Evidence of possible increased risk HIV and Pregnancy 3

Adverse Pregnancy Outcomes and Relationship to HIV Infection (continued) Pregnancy Outcome Relationship to HIV Infection Low birth weight Evidence of possible increased risk Preterm delivery Evidence of possible increased risk, especially w/ more advanced disease Pre-eclampsia No data Gestational diabetes No data Amnionitis Limited data; more recent studies do not suggest an increased risk; some earlier studies found increased histologic placental inflammation, particularly in those with preterm deliveries Oligohydramnios Minimal data Fetal malformation No evidence of increased risk HIV and Pregnancy 4

Mother-to-Child Transmission l 25– 35% of HIV positive pregnant mothers will pass HIV to their newborns l In the absence of breastfeeding: l 30% of transmission in utero l 70% of transmission during the delivery l Meta-analysis showed 14% transmission with breastfeeding and 29% transmission with acute maternal HIV infection or recent seroconversion De. Cock et al 2010; Dunn et al 2002; WHO/UNAIDS 2009. HIV and Pregnancy 5

Risk Factors for Mother-to-Child Transmission l Viral load (HIV-RNA level) l STDs and other coinfections l Genital tract viral load l Antiretroviral agents l CD 4 cell count l Preterm delivery l Clinical stage of HIV l Placental disruption l Unprotected sex with multiple partners l Invasive fetal monitoring l Duration of membrane rupture l Vaginal delivery vs. cesarean section l Breastfeeding l Smoking cigarettes l Substance abuse l Vitamin A deficiency HIV and Pregnancy 6

Interventions to Reduce Mother-to-Child Transmission l HIV testing in pregnancy l Antenatal care l Antiretroviral agents l Obstetric interventions Avoid amniotomy l Avoid procedures: Forceps/vacuum extractor, scalp electrode, scalp blood sampling l Restrict episiotomy l Elective cesarean section l Remember infection prevention practices l Newborn feeding: Breastmilk vs. formula l HIV and Pregnancy 7

HIV Testing during Pregnancy l Advantages: l Possible treatment of mother l Reduce risk of mother-to-child transmission l Future family planning issues l Precautions against further spread l If negative, advise about HIV prevention Counseling is important! HIV and Pregnancy 8

Antenatal Care l Most HIV-infected women will be asymptomatic l Watch for signs/symptoms of AIDS and pregnancy-related complications l Unless complication develops, no need to increase number of visits l Treat STDs and other coinfections l Counsel against unprotected intercourse l Avoid invasive procedures and external cephalic version l Give antiretroviral agents, if available l Counsel about nutrition HIV and Pregnancy 9

Antiretrovirals l Zidovudine (ZDV): l Long course l Short course l Nevirapine l ZDV/lamivudine (ZDV/3 TC) HIV and Pregnancy 10

ZDV Perinatal Transmission Prophylaxis Regimen: ACTG 076 Trial Antepartum Initiation at 14– 34 weeks gestation and continued throughout pregnancy l PACTG 076 regimen: ZDV 5 times daily l Acceptable alternative regimen: ZDV 2 or 3 times daily (depending on dose) Intrapartum During labor, ZDV IV over 1 hour, followed by a continuous infusion of IV until delivery Postpartum Oral administration of ZDV to newborn for first 6 weeks of life, beginning at 8– 12 hours after birth HIV and Pregnancy 11

Intrapartum vs. Postpartum Regimens for HIV-Infected Women in Labor with No Prior Antiretroviral Therapy Drug Regimen Nevirapine Maternal Intrapartum Newborn Postpartum One oral dose at at onset of age 48– 72 hours (if labor mother received nevirapine < 1 hour before delivery, newborn given oral nevirapine as soon as possible after birth and at 48– 72 hours) HIV and Pregnancy Data on Transmission at 6 weeks 12% with nevirapine compared to 21% with ZDV, a 47% (95% CI, 20– 64%) reduction 12

Intrapartum vs. Postpartum Regimens for HIV-Infected Women in Labor with No Prior Antiretroviral Therapy (cont’d. ) Drug Regimen ZDV/3 TC Maternal Intrapartum Newborn Postpartum Data on Transmission ZDV orally at onset of labor followed by dose orally every 3 hours until delivery AND 3 TC orally at onset of labor, followed by dose orally every 12 hours ZDV orally every 12 hours Transmission at 6 weeks 10% with ZDV/3 TC compared to 17% with placebo, a 38% reduction AND 3 TC orally every 12 hours for 7 days HIV and Pregnancy. 13

Intrapartum vs. Postpartum Regimens for HIV-Infected Women in Labor with No Prior Antiretroviral Therapy (cont’d. ) Drug Regimen ZDV Maternal Intrapartum Newborn Postpartum IV bolus, followed Orally every 6 by continuous hours for 6 infusion of every weeks hour until delivery HIV and Pregnancy Data on Transmission 10% with ZDV compared to 27% with no ZDV treatment, a 62% (95% CI, 19 -82%) reduction 14

Intrapartum vs. Postpartum Regimens for HIV-Infected Women in Labor with No Prior Antiretroviral Therapy (cont’d. ) Drug Regimen Maternal Intrapartum ZDV and Nevirapine IV bolus, then continuous infusion until delivery AND Nevirapine single oral dose at onset of labor Newborn Postpartum Data on Transmission Orally every 6 No data hours for 6 weeks AND Nevirapine single oral dose at age 48– 72 hours HIV and Pregnancy 15

Obstetric Procedures Because of increased fetal exposure to infected maternal blood and secretions, increased transmission may come from: l Amniotomy l Fetal scalp electrode/sampling l Forceps/vacuum extractor l Episiotomy l Vaginal tears HIV and Pregnancy 16

Delivery: Cesarean vs. Vaginal Birth l Risk of mother-to-child transmission increased 2% each hour after membranes have been ruptured l Cesarean section before labor and/or rupture of membranes reduces risk of mother-to-child transmission by 50– 80% compared with other modes of delivery in women on no antiretroviral therapy or on ZDV alone l No evidence of benefit with cesarean section after onset of labor or membranes have been ruptured l Cesarean section, however, increases morbidity and possible mortality to mother l Give antibiotic prophylaxis for cesarean section in HIV-infected women HIV and Pregnancy 17

Mode of delivery l Vaginal delivery is recommended for women on HAART with an HIV viral load <50 HIV RNA copies/ml at gestational week 36. l Delivery by pre-labour caesarean section (PLCS) is recommended for women taking zidovudine monotherapy irrespective of plasma viral load at the time of delivery and for women with viral load >400 regardless of ART. l Delivery by PLCS is recommended for women taking zidovudine monotherapy irrespective of plasma viral load at the time of delivery (Grading: 1 A) and for women with viral load >400 regardless of ART. HIV and Pregnancy 18

Recommended Infection Prevention Practices l Needles: l Take care! Minimal use l Suturing: Use appropriate needle and holder l Care with recapping and disposal l Wear gloves, wash hands with soap immediately after contact with blood and body fluids l Cover incisions with watertight dressings for first 24 hours HIV and Pregnancy 19

Recommended Infection Prevention Practices (continued) l Use: l Plastic aprons for delivery l Goggles and gloves for delivery and surgery l Long gloves for placenta removal l Dispose of blood, placenta and waste safely l PROTECT YOURSELF! HIV and Pregnancy 20

Newborn l Wash newborn after birth, especially face l Avoid hypothermia l Give antiretroviral agents, if available HIV and Pregnancy 21

Infant prophylaxis l Zidovudine monotherapy is recommended if maternal viral load is <50 HIV RNA copies/ml at 36 weeks gestation/delivery (or mother delivered by PLCS whilst on ZDV monotherapy), irrespective of the mother’s viral resistance pattern or drug history. l Infants <72 hours old, born to untreated HIV-positive mothers, should initiate three drug therapy immediately. l Three drug infant therapy is recommended for all circumstances where maternal viral load at 36 weeks gestation/delivery is not <50 HIV RNA copies/ml. l Neonatal PEP should be continued for 4 weeks. HIV and Pregnancy 22

Infant feeding l All mothers known to be HIV infected, regardless of antiretroviral therapy, and infant PEP, should be advised to exclusively formula feed from birth In the very rare instances where a mother who is on effective HAART with a repeatedly undetectable viral load chooses to breast feed, this should not constitute grounds for automatic referral to child protection teams. Maternal HAART should be carefully monitored and continued until one week after all breastfeeding has ceased. Breastfeeding, except during the weaning period, should be exclusive and all breastfeeding, including the weaning period, should have been completed by the end of 6 months l Prolonged infant prophylaxis during the breastfeeding period, as opposed to maternal HAART, is not recommended. l Intensive support and monitoring of the mother and infant are recommended during any breastfeeding period, including monthly measurement of maternal HIV plasma viral load, and monthly testing of the infant for HIV by PCR for HIV c. DNA or RNA (viral load). HIV and Pregnancy 23

Breasfeeding Issues l Warmth for newborn l Nutrition for newborn l Protection against other infections l Safety – unclean water, diarrheal diseases l Risk of HIV transmission l Contraception for mother l Cost HIV and Pregnancy 24

HIV DNA PCR (or HIV RNA testing) should be performed on the following occasions. l During the first 48 hours and prior to hospital discharge l 2 weeks post infant prophylaxis (6 weeks of age) l 2 months post infant prophylaxis (12 weeks of age) l On other occasions if additional risk (e. g. breast-feeding) l HIV antibody testing for seroreversion should be done at age 18 months. HIV and Pregnancy 25

Conclusion l Voluntary counseling and testing l Antenatal, intrapartum and postpartum care to mother can decrease risk of mother-to-child transmission l l Antiretroviral therapy can also reduce risk of transmission Newborn care: Feeding HIV and Pregnancy 26